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Morton's neuroma

25 citationsUpdated Sep 2026

Overview

Morton's neuroma is an interdigital nerve pathology where metatarsalgia serves as a primary symptom requiring careful differentiation into primary, secondary, or non-weight-distribution-related causes to determine appropriate treatment [8]. Nonoperative management is recommended initially, while operative treatment is indicated after nonoperative management has failed [14]. Patient-reported outcomes following resection of a symptomatic Morton's neuroma are acceptable but may not be as good as earlier studies suggest [1].

Conservative interventions include ultrasound-guided corticosteroid injection, which showed statistically significantly better functional and pain outcomes than ultrasound-guided hyaluronic acid injection for the treatment of Morton's neuroma at many timepoints [2]. However, ultrasound guidance did not demonstrably improve the efficacy of corticosteroid injections in patients with Morton's neuroma [3].

Surgical options vary in long-term reliability. Metatarsal osteotomy, long a staple of treatment, always fails in the long term, but improved equipment and internal fixation methods may lead to better long-term outcomes [7]. Among metatarsal osteotomies, the Weil procedure is reliable, while percutaneous methods require further evaluation [16]. Reoperation for persistent pain after initial excision of an interdigital neuroma is successful in relieving pain in the majority of patients, with 67% achieving complete relief or marked improvement [4]. Dorsal nerve transposition can be considered if one is concerned about stump neuroma, but this may be technically demanding and in some patients it may not be possible [6]. The outcome of endoscopic treatment of interdigital neuroma demonstrates the need for the surgeon to be meticulous in the identification of anatomic structures and cautious with regard to the surgical technique [10].

Anatomy & Pathophysiology

Nerve Anatomy

The tibial nerve divides into three terminal branches: the medial calcaneal nerve, lateral plantar nerve, and medial plantar nerve [26]. The lateral plantar nerve passes deep to the abductor fascia and plantar fascia, over the quadratus plantae, and continues distally under the flexor digitorum brevis [26]. It terminates in the fourth web space and supplies a branch to the third web space [26]. The medial plantar nerve innervates the abductor hallucis and continues under the abductor and plantar fascia to form common digital nerves that terminate in the first, second, and third web spaces [26]. Motor innervation is distributed such that the medial plantar nerve provides branches to the interossei and lumbricals, while the lateral plantar nerve supplies motor branches to the intrinsic muscles [26].

The fourth plantar digital nerve possesses a double origin, receiving one branch from the medial plantar nerve and one from the lateral plantar nerve [15]. After anastomosing, this nerve continues distally between the flexor brevis muscle and the plantar aponeurosis just proximal to the metatarsal heads [15]. It then penetrates the plantar aponeurosis and passes beneath the transverse metatarsal ligament [15]. Just distal to the transverse metatarsal ligament, the nerve turns upward into the web space between the third and fourth toes, where it divides into medial and lateral branches supplying the adjacent sides of these toes [15]. Notably, the fourth plantar digital nerve is thicker and more fixed than other plantar digital nerves [15].

Vascular and neural supply to the dorsal foot involves the deep peroneal nerve, which lies immediately lateral to the dorsalis pedis artery as it passes anterior to the ankle joint [27]. The first dorsal metatarsal artery, a continuation of the dorsalis pedis artery, runs distally on the dorsal surface of the first dorsal interosseous muscle [27]. This artery may lie superficial to or within the substance of the first dorsal interosseous muscle in 78% to 88% of feet, or plantar to the first metatarsal in 12% to 22% of feet [27]. The deep plantar, or communicating, artery leaves the dorsalis pedis at the base of the first metatarsal and passes toward the plantar surface between the heads of the first dorsal interosseous muscle, communicating with the lateral plantar artery to complete the plantar arterial arch [27]. The first plantar metatarsal artery continues distally in the first interosseous space [27]. Sensory innervation of the plantar surface is provided by digital branches of the medial plantar nerve [27], while the first web space is innervated by the deep peroneal nerve and the dorsal surfaces of the toes and foot receive sensory innervation through superficial peroneal nerve branches [27].

Pathophysiology

Morton's original explanation for the condition was a disturbance in the fourth metatarsophalangeal articulation or pinching of the digital branches of the lateral plantar nerve between the fourth and fifth metatarsal heads [15]. Betts ascribed the condition to a stretching and irritation of the fourth plantar digital nerve, theorizing that because this nerve is thicker and more fixed, it is prone to stretch [15]. Anatomically, the interosseous compartment of the foot lies dorsal to the medial, lateral, and central compartments and contains the digital nerves [33].

Classification

Historical Nomenclature: Morton originally described the condition in 1876 as a specific group of metatarsal pain cases [15]. Betts later described the syndrome in 1940, associating it with a change in the fourth plantar digital nerve [15].

Anatomical Basis: The fourth plantar digital nerve is anatomically distinct from other plantar digital nerves due to its double origin, receiving one branch from the medial plantar nerve and one from the lateral plantar nerve [15]. Distally, this nerve travels between the flexor brevis muscle and the plantar aponeurosis just proximal to the metatarsal heads, penetrates the aponeurosis, and passes beneath the transverse metatarsal ligament [15]. Immediately distal to the transverse metatarsal ligament, the nerve turns upward into the web space between the third and fourth toes, where it divides into medial and lateral branches supplying the adjacent sides of these toes [15].

Pathomechanism: Betts theorized that the fourth plantar digital nerve is prone to stretch because it is thicker and more fixed than other plantar digital nerves [15].

Clinical Presentation

Morton's metatarsalgia was originally described as a syndrome of plantar metatarsal pain [15]. Morton's initial explanation attributed the condition to a disturbance in the fourth metatarsophalangeal articulation or pinching of the digital branches of the lateral plantar nerve between the fourth and fifth metatarsal heads [15]. Betts later described the syndrome as one associated with a change in the fourth plantar digital nerve [15].

The fourth plantar digital nerve differs anatomically from other plantar digital nerves by having a double origin, with one branch from the medial plantar nerve and one branch from the lateral plantar nerve [15]. This nerve continues distally between the flexor brevis muscle and the plantar aponeurosis just proximal to the heads of the metatarsals [15]. It then penetrates the aponeurosis and passes beneath the transverse metatarsal ligament [15]. In the web space between the third and fourth toes, the fourth plantar digital nerve divides into medial and lateral branches which supply the adjacent sides of the third and fourth toes [15].

Betts theorized that the fourth plantar digital nerve is thicker and more fixed than other plantar digital nerves [15]. Consequently, because the fourth plantar digital nerve is thicker and more fixed, it is prone to stretch [15].

Investigations

Clinical Examination: The diagnosis of Morton's neuroma is usually established through a careful history and physical examination [36]. Characteristic symptoms include plantar foot pain just distal to and between the metatarsal heads, often described as “burning” [36]. Patients frequently report feeling as if they are walking on a marble [36]. Symptoms are typically aggravated by activity or by wearing shoes with high heels or a narrow toe box [36]. Conversely, patients often note that they feel better in their bare feet and get quick relief by removing their shoes [36]. The Mulder sign is elicited by squeezing the foot while palpating the web space, and a painful click is diagnostic of an interdigital neuroma [36]. Because neuromas rarely occur in the first and fourth web spaces, pain in these areas should prompt consideration of other causes of forefoot pain [36].

Plain Radiography: Weight-bearing radiographs are useful for excluding a stress fracture of the metatarsal neck in the evaluation of Morton's neuroma [36]. The radiographic evaluation for metatarsalgia includes weight-bearing anteroposterior, lateral, and oblique views of the foot [41]. The so-called skyline view of the metatarsal heads is helpful to evaluate their overall alignment, particularly in cases resulting from previous surgery [41].

MRI: MRI may be useful in the diagnosis of Morton's neuroma, and the administration of contrast medium may increase its accuracy [36]. MRI can also be useful in the diagnosis of metatarsalgia, such as distinguishing among a neuroma, cyst, bursa, or synovitis [41]. Unlike most other tumors, interdigital or Morton neuroma lacks increased signal on T2-weighted MRI sequences [43].

Ultrasonography: Ultrasonography has been reported to be 85% accurate in diagnosing interdigital neuroma [36].

Diagnostic Injection: Injection of the involved web space with local anesthetic that results in relief of the neuritic symptoms is diagnostic of Morton's neuroma [36]. A recent study suggested that injections performed under ultrasound guidance had higher short-term relief compared with blind injections for Morton's neuroma [36].

Other Considerations: Interdigital or Morton neuroma is most frequently found in the distal third metatarsal interspace [43].

Treatment

Non-Operative

Conservative management focuses on reducing mechanical stress and managing pain. Applying metatarsal pads is an effective method to reduce pressure loading under the metatarsal head and relieve symptoms of metatarsalgia [18]. Regarding injection therapy, ultrasound-guided corticosteroid injection showed statistically significantly better functional and pain outcomes than an ultrasound-guided injection of hyaluronic acid for the treatment of a Morton's neuroma at many timepoints [2].

Operative

Indications: Surgery is considered when conservative measures fail, though patient-reported outcomes after resection of a symptomatic Morton's neuroma are acceptable but may not be as good as earlier studies suggest [1].

Surgical Approach / Technique: The oblique osteotomy provided relief of plantar pain with a low complication rate, high union rate, and consistent results [21]. Distal metatarsal osteotomy by minimal invasive surgery could be a safe and effective surgical procedure to be considered for metatarsalgias of the lesser rays [13].

Other Considerations: Surgeons should pay more attention to reconstructing a foot where load can be evenly distributed, especially around the time metatarsalgia often occurs [12].

Complications

Surgical Complications and Outcomes

Recurrence: IML release with neurolysis carries a higher risk of symptom recurrence compared to interdigital neurectomy [19].

Iatrogenic Injury: Endoscopic treatment of interdigital neuroma has been associated with transection of the plantar plate and the flexor digitorum longus tendon of the fourth toe. These outcomes demonstrate the need for meticulous identification of anatomic structures and caution regarding surgical technique [10].

Technique Optimization: Safe zones for portal placement have been identified to minimize nerve injury and biomechanical changes during surgery [5].

Iatrogenic Transfer Metatarsalgia

Etiology: Screwless scarf osteotomy for hallux valgus appears to cause more shortening and transfer metatarsalgia [17].

Management: A comprehensive treatment algorithm for iatrogenic transfer metatarsalgia, classified by multiplanar assessment of malalignment, guides surgeons in addressing this complication and avoiding potential pitfalls in primary surgery [11].

Key Evidence

  • [L3] The patient-reported outcomes after resection of a symptomatic Morton's neuroma are acceptable but may not be as good as earlier studies suggest. [1] (10.1302/0301-620x.98b10.37610)
  • [L1] An ultrasound-guided corticosteroid injection showed statistically significantly better functional and pain outcomes than an ultrasound-guided injection of hyaluronic acid for the treatment of a Morton's neuroma at many timepoints. [2] (10.1302/0301-620x.106b10.bjj-2024-0342.r2)
  • [L1] Ultrasound guidance did not demonstrably improve the efficacy of corticosteroid injections in patients with Morton's neuroma. [3] (10.1302/0301-620x.98b4.36880)
  • [L4] Reoperation for persistent pain after initial excision of an interdigital neuroma is successful in relieving pain in the majority of patients, with 67% achieving complete relief or marked improvement. [4] (10.2106/00004623-198870050-00003)
  • [L5] The authors identify safe zones for portal placement and advocate for specific techniques to minimize nerve injury and biomechanical changes during surgery. [5] (10.1007/s00167-010-1096-2)
  • [L4] Dorsal nerve transposition can be considered if one is concerned about stump neuroma, but this may be technically demanding and in some patients it may not be possible. [6] (10.1186/s13018-022-02910-2)
  • [L4] Metatarsal osteotomy, long a staple of treatment, always fails in the long term, but improved equipment and internal fixation methods may lead to better long-term outcomes. [7] (10.5435/00124635-201008000-00004)
  • [L5] The outcome demonstrates the need for the surgeon to be meticulous in the identification of anatomic structures and cautious with regard to the surgical technique. [10] (10.2106/00004623-200410000-00026)
  • [L5] The authors present a comprehensive treatment algorithm for iatrogenic transfer metatarsalgia classified by multiplanar assessment of malalignment to guide surgeons in addressing this complication and avoiding potential pitfalls in primary surgery. [11] (10.1530/eor-22-0043)
  • [L3] Surgeons should pay more attention to reconstructing a foot where load can be evenly distributed, especially around the time metatarsalgia often occurs. [12] (10.1186/s13018-017-0622-z)
  • [L4] These results suggest that this could be a safe and effective surgical procedure to be considered for metatarsalgias of the lesser rays. [13] (10.1186/s13018-019-1159-0)
  • [L5] Nonoperative management is recommended initially, while operative treatment is indicated after nonoperative management has failed. [14] (10.1302/2058-5241.4.180025)
  • [L4] [15] (10.2106/00004623-194830020-00024)
  • [L4] Among metatarsal osteotomies, the Weil procedure is reliable, while percutaneous methods require further evaluation. [16] (10.1016/j.otsr.2016.06.020)
  • [Paper] However, it appears to cause more shortening and transfer metatarsalgia. [17] (10.1016/j.otsr.2021.102853)
  • [L4] Applying metatarsal pads is an effective method to reduce pressure loading under the metatarsal head and relieve symptoms of metatarsalgia. [18] (10.1186/1471-2474-7-95)
  • [L3] IML release with neurolysis seems to have a higher risk of symptom recurrence than interdigital neurectomy. [19] (10.5435/jaaos-d-23-01194)
  • [L4] The oblique osteotomy provided relief of plantar pain with a low complication rate, high union rate, and consistent results. [21] (10.1097/01.blo.0000229354.96996.3e)

See Also

References

[1] Outcomes following excision of Morton’s interdigital neuroma. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b10.37610

[2] Ultrasound-guided infiltration with hyaluronic acid compared with corticosteroid for the treatment of Morton’s neuroma. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b10.bjj-2024-0342.r2

[3] Corticosteroid injection for Morton’s neuroma with or without ultrasound guidance. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b4.36880

[4] Persistent pain after excision of an interdigital neuroma. Results of reoperation.. The Journal of Bone & Joint Surgery. 1988. DOI: 10.2106/00004623-198870050-00003

[5] Surgical approaches to the forefoot for common sports‐related pathologies: a review of the literature and cadaveric dissection. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1096-2

[6] Long-term results of dorsal neuroma/nerve transposition in the surgical management of Morton’s neuroma and correlation with intraoperative anatomical variations. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-02910-2

[7] Metatarsalgia. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201008000-00004

[8] Metatarsalgia: diagnosis and treatment.. The Journal of Bone and Joint Surgery. American Volume. 1980.

[10] Transection of the Plantar Plate and the Flexor Digitorum Longus Tendon of the Fourth Toe as a Complication of Endoscopic Treatment of Interdigital Neuroma. The Journal of Bone & Joint Surgery. 2004. DOI: 10.2106/00004623-200410000-00026

[11] Iatrogenic transfer metatarsalgia after hallux valgus surgery: a comprehensive treatment algorithm. EFORT Open Reviews. 2022. DOI: 10.1530/eor-22-0043

[12] Loading pattern of postoperative hallux valgus feet with and without transfer metatarsalgia: a case control study. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0622-z

[13] Evaluation of results after distal metatarsal osteotomy by minimal invasive surgery for the treatment of metatarsalgia: patient and anatomical pieces study. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1159-0

[14] Morton’s interdigital neuroma: instructional review. EFORT Open Reviews. 2019. DOI: 10.1302/2058-5241.4.180025

[15] MORTONʼS METATARSALGIA. The Journal of Bone & Joint Surgery. 1948. DOI: 10.2106/00004623-194830020-00024

[16] Metatarsalgia. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.06.020

[17] Does screwless scarf osteotomy for hallux valgus increase the risk of transfer metatarsalgia?. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102853

[18] Correlations between subjective treatment responses and plantar pressure parameters of metatarsal pad treatment in metatarsalgia patients: a prospective study. BMC Musculoskeletal Disorders. 2006. DOI: 10.1186/1471-2474-7-95

[19] Factors Associated With Symptom Recurrence After Surgical Treatment of Interdigital Neuroma: A Retrospective Chart Review of 127 Patients. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01194

[21] Resolution of Metatarsalgia following Oblique Osteotomy. Clinical Orthopaedics & Related Research. 2006. DOI: 10.1097/01.blo.0000229354.96996.3e

[26] Campbell S Operative Orthopaedics 4 Volume Set. COMBINED HAMMER TOE AND MALLET TOE DEFORMITY WITH ASSOCIATED DOUBLE CORNS > TARSAL TUNNEL SYNDROME.

[27] Campbell S Operative Orthopaedics 4 Volume Set. RESULTS OF SUTURE OF THE SCIATIC NERVE > NEUROVASCULAR ANATOMY.

[33] Rockwood And Green S Fractures In Adults. Effect of Blast on the Musculoskeletal System > Foot.

[36] Aaos Comprehensive Orthopaedic Review 3. Neurologic Disorders of the Foot and Ankle > II. Interdigital Neuroma.

[41] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 8Foot and Ankle Surgery > METATARSALGIA.

[43] Campbell S Operative Orthopaedics 4 Volume Set. OTHER DISORDERS OF FOOT AND ANKLE.

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b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.